Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature

Abstract

SummaryKeloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.What's already known about this topic?• Keloid disease (KD) is a common, benign, fibroproliferative tumour of unknown origin.• With high recurrence rates, treatment of KD remains a challenge for both the patient and clinician.• With lack of level-one evidence, there is no single advocated therapy.What does this study add?• A structured strategic approach for management of KD by utilizing a focused history, targeted therapy and regular follow-up of the patient.• Patients' symptoms, signs, quality of life and psychosocial well-being should be carefully evaluated and managed.

The management of helical rim keloids with excision, split thickness skin graft and intralesional triamcinolone acetonide

“…Keloid can develop at any age, but tends to be most prevalent in individuals aged between 10 and 30 years. [7] In this study, the incidence is approximately equal for male and female, and the patients were in the same age range as described in most reports. The onset was following trauma in four patients.…”

Evidence of selection as a cause for racial disparities in fibroproliferative disease

“…Many fibroproliferative diseases are more prevalent in recently African-derived populations than in European populations[3], collectively contributing to pronounced overall health disparity (Table 1). For example, keloids are more common in those with darker pigmentation[4], and systemic scleroderma[5, 6], nephrosclerosis[7], and sarcoidosis[8] are more prevalent in African American individuals. However, this is not the case for all fibroproliferative diseases.…”

Spray versus intralesional cryotherapy for keloids

“…Many treatment modalities -such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy -are being used for the management of keloids (3).…”

“…Cryotherapy can be applied locally through various techniques to treat many skin conditions including keloids (3). The therapeutic effects of cryotherapy depend on direct cell damage and changes in the microcirculation provoked by freezing that cause vascular damage and blood stasis leading to cell anoxia (4).…”